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Hindawi Publishing CorporationMinimally Invasive SurgeryVolume 2012, Article ID 347607, 9 pagesdoi:10.1155/2012/347607

Review Article

Single-Incision Laparoscopic Cholecystectomy: Is It a PlausibleAlternative to the Traditional Four-Port Laparoscopic Approach?

Juan Pablo Arroyo,1 Luis A. Martın-del-Campo,2 and Gonzalo Torres-Villalobos2, 3

1 Molecular Physiology Unit, Instituto de Investigaciones Biomedicas, Universidad Nacional Autonoma de Mexico andInstituto Nacional de Ciencias Medicas y Nutricion Salvador Zubiran, Zubiran, 14000 Mexico, df, Mexico

2 Surgery Department, Instituto Nacional de Ciencias Medicas y Nutricion Salvador Zubiran, Zubiran,14000 Mexico, DF, Mexico

3 Experimental Surgery Department, Instituto Nacional de Ciencias Medicas y Nutricion Salvador Zubiran, Zubiran,14000 Mexico, DF, Mexico

Correspondence should be addressed to Gonzalo Torres-Villalobos, [email protected]

Received 4 December 2011; Accepted 23 February 2012

Academic Editor: Boris Kirshtein

Copyright © 2012 Juan Pablo Arroyo et al. This is an open access article distributed under the Creative Commons AttributionLicense, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properlycited.

The current standard-of-care for treatment of cholecystectomy is the four port laparoscopic approach. The development of singleincision/laparoendoscopic single site surgery (SILC/LESS) has now led to the development of new techniques for removal of thegallbladder. The use of SILC/LESS is now currently being evaluated as the next step in treatment of cholecystectomy. This reviewis an attempt to consolidate the current knowledge and analyze the feasibility of world-wide implementation of SILC/LESS.

1. Introduction

The ultimate goal of surgery has always been providing thebest and most effective procedure with the least amount ofpostoperative complications, and pain and the best possibleaesthetic results. Surgery of the biliary tract is by no meansthe exception. The first reported elective cholecystectomywas carried out by Langenbuch in 1882 [1] and open chol-ecystectomy became the standard-of-care well into the 1980swith mortality rates at less than 1%, and bile duct injuriesaffecting 0.1-0.2% of patients [2, 3]. This approach howeverrequired a large abdominal incision associated with signifi-cant postoperative pain and a longer convalescence.

A revolution in the surgical treatment of biliary diseasecame in the 1980s with the introduction of laparoscopic sur-gery. The first laparoscopic cholecystectomy was performedby Muhe [4] however his approach did not become popularuntil both French and American groups popularized thefour-port technique in the early 1990s. The idea of minimallyinvasive surgery for the removal of the gallbladder had nowbecome a plausible technique that was rapidly accepted asthe standard-of-care. Patients quickly learned of the new

procedure and began to request it on the basis of a shorterhospital stay, less pain, and smaller scars [5]. The possibilityof performing laparoscopic cholangiography, common bileduct exploration, and choledochotomy expanded the role oflaparoscopic surgery in the treatment of biliary disease [6]and further advanced the idea of minimally invasive surgeryas the gold-standard for surgery of the biliary tract.

Recently the development of natural orifice transluminalendoscopic surgery (NOTES) opened the field of incision-less surgery. The main goal of NOTES is to eliminate the needfor skin incisions along with other theoretical advantageswhich include: decreased postoperative pain, performingprocedures in the out-patient setting, reduced incidence ofhernias, reduced hospital stay, and increased overall patientsatisfaction [5, 7]. The idea of accessing internal organsthrough the wall of the vagina, colon, stomach, bladder, andso forth, with the use of rigid or flexible instruments isan attractive one. However, the challenge of obtaining aclean access site thereby preventing intra-abdominal spillageor infection from the incision has not been able to befully avoided [7]. Additionally the concern over closure ofthe luminal incision and the lack of a single effective

2 Minimally Invasive Surgery

closure technique for stomach, esophagus, or colon, so farlimits the application of this technique. Moreover, the pos-sibility of generating bowel-overdistention due to the pneu-moperitoneum required for adequate visualization of intra-abdominal structures is still a concern [5]. With currentongoing research on the efficacy and safety of NOTES it isstill premature to advocate it as an alternative to laparoscopicsurgery of the biliary tract.

Single-incision laparoscopic surgery or SILS refers to theoperative technique in which a surgical procedure is carriedout through one incision, alternatively it is also knownas laparoendoscopic single site (LESS) surgery. In 1997Navarra et al. described a single-incision laparoscopic chol-ecystectomy as a plausible alternative procedure to the four-port laparoscopic cholecystectomy [8]. The use of a singleumbilical incision to remove the gallbladder was an interest-ing innovation and, since Navarra’s initial description, thesingle-incision laparoscopic cholecystectomy (SILC) proce-dure has gained momentum. The goals of SILC/LESS chole-cystectomy are similar to the goals behind the developmentof NOTES: decreased pain, decreased length of hospital stay,better aesthetic results, and increased patient satisfactionamong others [6, 9]. Multiple articles regarding the use ofSILC/LESS cholecystectomy have been published since theinitial two studies were published by Bresadola et al. [10] andPiskun and Rajpal [11], leading to a wealth of informationregarding the possible adoption of the SILC/LESS cholecys-tectomy by surgeons worldwide, including a 2010 consensusstatement by the Laparoendoscopic Single-Site Surgery Con-sortium for Assessment and Research (LESSCAR) [9]. It isour goal to review the different SILC/LESS cholecystectomytechniques reported so far along with the results associatedwith the most recent SILC/LESS cholecystectomy trials.

2. Technical Aspects of LaparoendoscopicSingle Site Cholecystectomy

Due to the growing experience and development of portsand instrumentation, surgical technique for LESS chole-cystectomy is rapidly evolving [21]. A particular technicalchallenge for the LESS approach is limited triangulationdue to confinement of both optics and working instrumentsto a single axis. Researchers and the industry are pursuingsolutions to this through the development of next-generationinstruments (Angled, flexible, articulated, and motorized)[9].

Given this, there is a wide variation of methods regardingthe type of ports, trocars, optics, instruments, and methodsto expose and dissect the gallbladder (Table 1). Nevertheless,many LESS procedures (including cholecystectomy) havebeen successfully performed with conventional laparoscopicinstruments.

2.1. Surgical Technique

2.1.1. Patient Position. The patient is placed in supine or thesplit-leg position, with the surgeon standing on the patient’sleft [22] or between the patient’s legs [23]. According to

Table 1: Commercially available multiport systems.

Port system Manufacturer

AnchorPort Surgiquest Inc (Orange, CT, USA)

GelPOINTApplied Medical (Rancho Santa Margarita, CA,

USA)

SILS Port Covidien (Norwalk, CT, USA)

TriPort Advanced Surgical Concepts (Wicklow, Ireland)

Uni-X SinglePort

Pnavel Systems (Brooklyn, NY, USA)

the surgeon’s position, the assistant is placed either on thepatient’s right or left. After access to the abdominal cavity isobtained, the patient will be placed in reverse Trendelenburgwith a slight rotation to the left to clear abdominal organsfrom the gallbladder [24].

2.1.2. Abdominal Cavity Access. Access can be accomplishedby two approaches [25]:

(i) LESS devices (Table 1) are designed to deploythrough a single incision (typically at the umbilicus)and require a fascial incision of approximately 15 to25 mm [14];

(ii) single incision with multiple trocars uses commer-cially available laparoscopic ports placed through asingle incision with a bridge of fascia between them[26]. A particular concern about this approach is therisk for increased hernia rates given the unknowneffect of multiple fascial punctures in proximity [25],although to this date, there are no reports of differenthernia rates between these two approaches.

2.1.3. Gallbladder Exposure. Most of the initial experience inLESS cholecystectomy relies on gallbladder suspension usingtransparietal stitches [6, 27]. Although different approacheshave been described, the principle is to place one to threestitches in the gallbladder fundus and/or infundibulum andapply different degrees of tension to expose the Calot’striangle while using another instrument to dissect [28].

Nevertheless, some authors advocate for abandoningtransparietal stitches for exposure, as they may be associatedwith accidental puncture and a potential oncological risk[21]; therefore, they prefer an intracorporeal grasper placedthrough a transumbilical port or a SILS port to gain dynamicexposure. Also, the use of an additional 1.8 to 3 mm grasperintroduced through the skin has been used to assist cephaladretraction and has not been considered as conversion in re-cent clinical trials [18, 19]. There is also a report of extra-corporeal retraction using magnet forceps attached to thegallbladder [29].

2.1.4. Calot’s Triangle Dissection. One should always considerthat a less invasive procedure must also be safe. Therefore,every effort must be made to comply with the requirementsof the critical view of safety for laparoendoscopic cholecys-tectomy [30], that comprises dissection of the neck of gall-bladder off the liver bed to achieve conclusive identification

Minimally Invasive Surgery 3

of the two structures to be divided: the cystic duct and theartery.

Instruments used for this purpose are very similar tothose of 4-port laparoscopic cholecystectomy and include5 mm hook, dissector scissor, and angle dissector. The cysticduct and artery are then dissected free, secured with clips,and divided [22].

2.1.5. Gallbladder Bed Dissection. Although gallbladder dis-section can be accomplished with a fundus-first technique[19], we encourage to do it after preparation of the cysticduct and artery (Strasberg critical view). Dissection is usuallyperformed with a hook type electrocautery device [24].

2.1.6. Extraction. After cholecystectomy has been completed,the gallbladder can be extracted through the LESS port,as it acts as a wound protector [17], or using a specimenbag that is introduced through the umbilical port whentraditional laparoscopic instruments are being used. Whenusing laparoscopic instruments, extraction through 5 mmports is unfeasible and they will need to be increased to 10or 12 mm [6].

2.1.7. Wound Closure. The fascial incision is closed with afigure of eight stitch [18]. Deep dermis of the umbilicus isreapproximated to ensure cosmesis [23].

2.2. Current Application. The current status of single-sitesurgery poses several technical difficulties for the surgeon[9], and cholecystectomy has not been the exception. Currentconsensus recommends that LESS procedures are only per-formed in centers with adequate laparoscopic experience andby surgeons with a certain amount of LESS surgical training[9].

Nevertheless, Mutter et al. have shown that LESS chol-ecystectomy can be safely implemented in a teaching hospitalwith both senior and junior laparoscopic surgeons [31]. Forsurgeons that are proficient with multi-incision laparoscopiccholecystectomy, the learning curve for LESS cholecystec-tomy begins near proficiency with infrequent complicationsand conversion rates [32].

2.3. Technical Strategies. In order to overcome the limitationsof triangulation with the LESS approach, several approacheshave been proposed. Curved and or articulated instrumentshave been used according to the surgeon’s preference [14],as they may allow to work on the operative field withouta straight approach from the access port. Using theseinstruments requires the instrument from the right hand tobe on the left side of the screen and the left-hand instrumentto be on the right side of the screen [6, 33].

One can choose an instrument with handles that arearticulated so they are away from each other at the accessport or use ports with a lower external or internal profilefor a wider range of instrument motion. Also, instrumentsof variable lengths allow for external manipulation so thatthey are operated in different planes, thus avoiding collisions[25].

3. Patient Outcomes: SILC/LESScholecystectomy versusFour-Port Cholecystectomy

In spite of numerous reports regarding the safety and efficacyof the SILS/LESS cholecystectomy approach, laparoscopiccholecystectomy (LC) still remains the gold-standard for thesurgical removal of the gallbladder [6]. Thus the compar-ison of patient outcomes between both procedures is ofkey importance. In this respect several prospective studiescomparing LC and SILC/LESS Cholecystectomy have nowbeen published [12–20] (Table 2).

There are several blinded randomized trials comparingstandard LC to SILC/LESS cholecystectomy with varied re-sults regarding patient outcomes. An outcome that has had asignificant difference in several studies comparing SILC/LESScholecystectomy versus LC is the cosmetic result. Patientsare more satisfied with the hidden or infraumbilical singlesurgical scar than the four scars created by the LC [13, 17,19]. In an attempt to try and reduce the bias associatedwith cosmetic evaluation, Marks et al. and Bucher et al.used body image scale, a scar scale photo series 10-pointscoring questionnaire in order to compare results betweenSILC/LESS and LC patients. However regardless of the scaleused, there is still an element of personal preference andopinion involved with the evaluation of cosmetic results.

Aside from cosmetic perception, the only consistentlyreproducible and statistically significant result among seriesis a prolonged time of surgery for the SILC/LESS cholecys-tectomy groups versus standard LC groups [12–14, 16–20].A study by Qiu et al. [34] focused specifically on the learningcurve phenomenon associated with SILC/LESS cholecystec-tomy and saw an improvement in operative times as experi-ence was gained [34] this was similar to what was observedby others [18–20]. The increased operating time may be acombination of factors among which the lack of surgeonexperience and the technical difficulty behind SILC/LESScholecystectomy could be involved. However, increased oper-ating time means increased duration of general anesthesiaand thus increased patient risk. Although no anesthesia-related complications were reported in the mentioned trials,a significant number of the studies used ASA class III or IVas a cut-off point for patients suitable for SILC/LESS chol-ecystectomy [13, 14, 19], thus the use of SILC/LESS cholecys-tectomy in patients in which there are foreseeable anesthesia-related complications remains limited.

One of the ultimate goals of the development of SILS/LESS cholecystectomy is a reduction in postoperative painperception and a decreased used of analgesic medications [9].The evaluation of postoperative pain is consistently includedas a primary or secondary outcome in recent studies [12–20]but lacking in previous studies [6]. The outcome howeverremains obscure as there are reports in which there is nodifference in pain perception between SILC/LESS cholecys-tectomy and LC groups [14, 16, 18], increased perceptionin the SILC/LESS cholecystectomy group [15, 19], and de-creased pain perception in the SILC/LESS cholecystectomygroups [12, 17]. The lack of consistent evidence regarding


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pain perception requires further evaluation in randomizedclinical trials.

In comparing outcomes between procedures, one of thekey points to evaluate is the presence or absence of intraop-erative and postoperative complications. A procedure can beconsidered safe only if the rate of complications is similarto that of the current gold-standard. When comparing therate of complications between SILC and LESS cholecystec-tomy numerous studies have reported both, no significantdifference with regard to complication rate [6, 15, 17, 22] oran increased complication rate when comparing SILS/LESScholecystectomy to LC [14, 18]. With regard to the studyby Phillips et al. [14] it is interesting to note that this isthe same cohort of patients as an initial report by Markset al. In the original report by Marks et al. [13] there wasno significant difference in complications. However in thereport by Phillips et al. [14], the number of patients increasedand so did the complications associated with single-incisionsurgery [14]. This is the largest case series published so farand in theory the learning curve has leveled off, indicatingthat the complications are inherent to the procedure itself,questioning the feasibility of widespread application of theSILC/LESS cholecystectomy. One of the complications thathas been discussed the most is the increased risk of apostincisional hernia after SILS/LESS surgery due to anincrease in size of the defect in the fascia. This complicationhas tried to be avoided by turning multiple fascial defects intoa single incision, however, results have been inconclusive.[6, 14, 25, 35].

Previous data on patient outcomes after SILC/LESS chol-ecystectomy suggest that this new procedure is reproducibleand safe [9], however this does not seem to agree with theresults from the recent RCTs (see above). The literature onSILS/LESS cholecystectomy has been recently reviewed byAntoniou et al. [6]. They analyzed the results of 29 differentarticles reporting the realization of a SILC/LESS cholecys-tectomy with a total of 1166 patients. Among the reportedresults there is 9.3% of unsuccessful surgery, generally dueto a lack of proper identification of Calot’s triangle, alongwith a cumulative intraoperative complication rate of 2.7%(range 0–20%) with the most common being gallbladderperforation/bile spillage (2.2%) and hemorrhage (0.3%).The most common postoperative complications were woundinfection and hematoma in 2.1% of patients [6].

In more recent articles Duron et al. and Mutter et al.reported series of 55 and 58 patients, respectively, who un-derwent SILC/LESS Cholecystectomy [31, 36]. Duron et al.[36] reported a series of 55 cases performed in a singleinstitution, in which a “learning curve” effect was presentwith regard to shorter operating times and the inclusionof more technically difficult patients as surgeon experienceincreased [36]. Mutter et al. [31] analyzed the implementa-tion of this type of surgery in a teaching hospital comparingsix surgeons (3 senior surgeons and 3 junior surgeons)finding no significant difference between operating times orcomplication rates, thus advocating the safe implementationof SILC/LESS cholecystectomy in teaching hospitals [31].These results however, include a limited number of surgeonsand are applicable only to patients with programmed

cholecystectomies without any foreseeable factors aggravat-ing dissection of Calot’s triangle as out of the 58 patients only3 were diagnosed with acute cholecystitis, thereby limitingtheir applicability.

In a matched pair analysis that took place over 26months, Gangl et al. [20] compared operating time, post-operative pain using the visual analogous scale (VAS) at 24and 48 hrs, use of analgesics, length of hospital stay, andcomplications [20]. They performed the SILC/LESS patientdata gathering prospectively, comparing them to matchedcontrols from a group of 163 LC which were performedin the same time period, with no significant differences inage, gender, BMI, ASA classification, diagnosis of acute chol-ecystitis, or previous abdominal surgery. They reported aSILC/LESS cholecystectomy completion rate of 85.1%, withconversion to LC in 9 patients and open cholecystectomy in1 patient due to inadequate visualization of the anatomy,versus a 100% completion rate in the LC group, with nosignificant difference with regard to postoperative pain, anal-gesic use, length of stay or complications. The only signifi-cant difference was the length of surgery with a longer oper-ating time in the SILC/LESS cholecystectomy group (75 minversus 63 min). They conclude that SILC/LESS even thoughassociated with a longer operating time is comparable to LC[20].

The incidence of biliary injury during standard LCvaries from 0.5 to 0.8% [37]. In order to identify biliaryinjury the use of intraoperative cholangiogram is nowconsidered a standard procedure to evaluate anatomy of thebiliary tree. The possibility of carrying out a transoperativecholangiogram in SILC/LESS was recently evaluated by Yeoet al. [38]. They were able to observe that in the 55 patientsin which a successful SILC was carried out, 53 received atransoperative cholangiogram out of which 48 were normalwith 1 patient requiring endoscopic removal of a biliary stone[38]. This is the largest series of SILC/LESS which reports theroutine evaluation of biliary anatomy with a cholangiogramperformed through an umbilical port, however, whetherthese results are reproducible or not, requires further studies.A more pressing issue regarding biliary injury and SILC/LESSis an adequate exposure of Calot’s triangle or “the Strasbergcritical view.” As described above, in order to achieve the“critical view,” the use of transparietal sutures or magneticforceps that allow extra corporeal traction on the gallbladderfundus can be carried out [6, 21, 29]. It is interesting to notethat in the study carried out by Antoniou et al. [6], the twomost common reasons for conversion from SILC/LESS tostandard LC were: Inflammation/adhesions/unclear anatomy(47.4% of all conversions) and inadequate visualizationof Calot’s triangle (23.7% of all conversions) with a totalrate of 5.2% and 2.6%, respectively [6]. The lack of anadequate identification of the anatomical landmarks be it byinflammation, adhesions, or normal anatomical variants isworrisome due to the increased incidence of bile duct injuriesin the presence of a less than adequate exposure [39].

When comparing costs, the cost of SILS/LESS cholecys-tectomy was increased compared with that of LC in spite ofthe authors in the Bucher et al. [21] study reutilized as muchmaterial as possible. They hypothesized that the costs are


a reflection of product development, and that as of now costsare not comparable to those of a routine procedure such asLC [17]. In contrast, a study by Love et al. [40] in which costcomparison between 20 patients undergoing each proceduredid not yield a significant cost difference [40]. Thus the issueof comparing cost is far from over, particularly if there arestill a myriad of technical options available for the realizationof a SILC/LESS cholecystectomy and there is no standardizedinstrumentation.

4. Conclusions

Current evidence suggests that even though patients preferthe cosmetic result of SILC/LESS cholecystectomy over atraditional laparoscopic approach [41], SILC/LESS chole-cystectomy is still a long way off from replacing laparo-scopic cholecystectomy as the gold-standard for surgicalremoval of the gallbladder. Insufficient evidence regardingthe safety, complication rate, and costs seems to precludethe worldwide implementation of this minimally invasiveprocedure. Additional concerns exist regarding patient safetyif it is not a programmed surgery, thus rendering SILC/LESScholecystectomy unavailable to a large subset of patients.Initial data showing increased complication rate alongwith a longer operating time, lack of standardization, andinstrumentation makes SILC/LESS cholecystectomy still anexperimental procedure that requires further development inorder to be applicable to general surgeons worldwide.

Authors’ Contribution

All the authors contributed equally.

Conflict of Interests

The authors have no conflicting interests.

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